Trick of the Trade: Dermal Avulsion Injuries 2.0

2016-11-11T19:39:55+00:00

Take a shortened, piece of rubber tourniquet and encircle the finger, then clamp it with a needle driver.This year I published a Novel, Simple Method for Achieving Hemostasis of Fingertip Dermal Avulsion Injuries in the Journal of Emergency Medicine 1  a technique I’ve used in my local ED for several years. In brief, this involves achieving hemostasis over a fingertip skin avulsion by using a tourniquet followed by tissue adhesive glue. After bringing the technique to press and sharing this video, I’ve received great tips from peers and subsequently refined it with some additional ideas.  Thus I present for the first time on ALiEM: Dermal Avulsion Injuries 2.0.

 

 

The video above illustrates the entire revised technique in detail, while the outline below highlights the key concepts in the technique revision:

1. Start with an “epi dip.”

The first step in caring for any minor wound is controlling the patient’s pain. In my article, I recommended digital blockade for this purpose. While this works, there is a better way, and it was described right here at ALiEM in 2011. As a means of anesthesia, have the patient dip the injured finger in 1% lidocaine with epinephrine for 5 minutes. One can pour 10-20 cc of this solution into a small medicine cup or urine specimen cup, and the patient simply soaks the afflicted finger.

Soaking the injured digit in 1% lidocaine with epinephrine provides analgesia and helps decrease bleeding through vasoconstriction.

Soaking the injured digit in 1% lidocaine with epinephrine provides analgesia and helps decrease bleeding through vasoconstriction.

 

Epinephrine has the added benefit of vasoconstricting the troublemaking-little bleeders that necessitated use of the technique in the first place. In fact, in the 2011 post, it was described as a sole means of achieving hemostasis. I would argue that it’s a good start, but the epinephrine effect alone is not enough to get the job done.

Thus, it’s a perfect first step for the technique that follows.

2. Apply the “just right” tourniquet.

Applying a tourniquet can be tricky. Sometimes it is difficult to achieve the level of tightness that achieves hemostasis without making it so tight that the patient can’t handle the discomfort. There are commercial tourniquet systems available that mean to circumvent this problem, but they can be expensive and are not readily available to all providers.

Quick bedside solution: Take your usual IV start tourniquet. Generally these are on the wide side, so slice it in half lengthwise with a pair of trauma shears if you prefer. Encircle the proximal digit, then clamp it with a needle driver. Crank the driver until you’ve achieved a level of compression that stops the bleeding from the wound, but remains tolerable for the patient. I have found that the right number typically falls between 5-10 “twists.” Apply the tissue adhesive glue over the dermal avulsion. When the glue is dry, it is time to release the tourniquet. This is done by simply releasing the needle driver. Thanks to Dr. Jeannie Tyan for this tip!

Take a shortened, piece of rubber tourniquet and encircle the finger, then clamp it with a needle driver.

Take a shortened piece of rubber tourniquet and encircle the finger, then clamp it with a needle driver.

 

Twist the needle driver to crank the tourniquet tighter, adjusting to a level that provides hemostasis but is tolerable for the patient.

Twist the needle driver to crank the tourniquet tighter, adjusting to a level that provides hemostasis but is tolerable for the patient.

 

3. Apply the tissue adhesive glue and create a “mini blow dryer” for a quick-dry

In order for this technique to be effective, preparation is key: the limb must be elevated, the tourniquet needs to be applied, the digit must be exsanguinated–or else you end up with a bloody, gluey mess. Then, the glue must be totally dry before the tourniquet is released and the limb is lowered. The glue, however, may not dry quickly. Especially with deeper avulsions, the glue almost seems to form a little pool within the wound that can exceed the digital tourniquet time with which I am comfortable.

Solution: Take suction tubing, hook it up to a compressed air source, and use it as a mini “blow dryer” for the wound. The patient can control the dryer while you handle other tasks. I’ve found use of this method significantly reduces tourniquet time, overall procedure time, and patient satisfaction. Thanks to Leonard Ng (Kaiser San Francisco ED technician) for this tip!

IMG_1721

Suction tubing can be attached to a compressed air source or oxygen tank and used as a blow dryer for the tissue adhesive glue.

 

Final thoughts

These simple modifications to the dermal avulsion hemostasis technique can be generalized to the care of many wounds of the fingers where you might not initially consider tissue adhesive glue as an option. I have used combinations and iterations of these tricks for bleeding lacerations up and down the finger that I thought I would have to suture. Keep these pearls in mind when you are doing your next shift around dinner time when a novice chef comes in with a sliced fingertip!

1.
Lin B. A novel, simple method for achieving hemostasis of fingertip dermal avulsion injuries. J Emerg Med. 2015;48(6):702-705. [PubMed]

Brian Lin, MD
UCSF Assistant Professor of Emergency Medicine
Kaiser Permanente Hospital, San Francisco, CA
Founder and author, LacerationRepair.com
  • Copyeditor note:
    Great insights into this trick of the trade post, addressing nuanced pearls on achieving hemostasis for finger dermal avulsions. I made some minor edits:
    1. In the first paragraph, it was never mentioned what the original trick was — hemostasis with tourniquet and then glue.
    2. I try to keep headers to as few words as possible. Hope it’s ok but I trimmed down for you.
    3. In tip #3 you mention that the limb is lowered, but there is no mention previously of elevating the limb. Can you fix this?
    4. Can you embed the youtube video? Just paste in the entire URL link in a blank line within WordPress.

    Otherwise, a great post as always. Especially love that you included a high-quality video of the technique. Thank you for all that you do to improve medical education on ALiEM and LacerationRepair.com.

  • Rob Bryant

    Brian,
    This is a great post and provides a great solution to a challenging problem that we frequently encounter in the ED. (I had consecutive shifts recently where misuse of a pampered chef slicer caused an avulsion injury in 2 patients).
    I have previously tried and failed to achieve hemostasis with the use of Surgicell hemostatic dressing.
    The video is excellent and provides a nice walk through for the procedure.
    The ‘just right’ tourniquet is a great idea.
    How may turns do you typically have to make to achieve enough pressure to provide hemostasis?

    Exsanguinating the finger makes sense and is likely one of the reasons I have failed to achieve hemostasis in these injuries in the past.
    What is your failure rate with this procedure?, and if it fails, what are your next steps?

    Are there any other steps that you would recommend for patients on anticoagulants?
    Would you consider a ‘TXA dip’ or the application of TXA soaked gauze after the exsanguination, and before the skin adhesive?

    The medical dogma regarding epi and fingers has been debunked several times over, however there are still health care providers that are fearful of using epi in any form near a finger. Do you think it is worth addressing this in your final thoughts section?
    Thanks for this great post, I am now excited to see my next fingertip skin avulsion injury.

    Rob Bryant MD

  • Hey folks,

    One other trick for a tourniquet that ortho recently showed me was the following:

    Take a sterile glove a size or so below what the patient may otherwise use. cut off a “sterile glove finger” and cut the tip off of it as well such that you are left with a tube of sorts. Roll it up to the mcp joint and voila, you’ve got a less messy tourniquet.

    Cheers. Happy repairing!
    Patrick

    • Thanks for the tip, Patrick. I wrote about this a while back at: https://www.aliem.com/trick-of-trade-hemostasis-of-finger/ – I don’t like the whole-glove technique you describe as much, since often the patient’s hand is bloody and a sterile glove is hard to pull over the sticky hand. Regardless, I’ve been using the twisty-tourniquet described by Brian above for a while now. The finger/hand-glove technique often doesn’t QUITE get the right amount of tension (too tight or too loose) and it’s hard to adjust the tension.

  • don zweig

    have been stopping all sorts of bleeding wounds for years with glue. even the bloody mess it creates works. this is better tho. however i always thought that the “drying” of glue was chemical and not heat or air related and thus blowing on it would not help?

    • Brian Lin, MD, FACEP

      Hi Don, thanks for your comment. You actually make a great point–drying is chemical and the makers of the product don’t recommend fanning or blowing as a means to make it dry faster. All I can say is that, for whatever reason, I have found that it does seem to help in this particular situation. My guess is that when you apply tissue adhesive glue to this type of injury, it typically forms a deep pit or well of liquid glue, and that takes forever and a day to dry. The blowing removes the excess on the top layer (essentially blowing it off) and exposes the bottom polymerized layer, thus decreasing time until the next layer of application. Arguably this could be done with gauze, but then you ruin the effect of the non-messy, hemostatic patch. Thanks again for reading and your comment!

  • Iwan Dierckx

    Great trick to stop the bleeding, but what about wound healing? Will having a ‘well’ of glue in the wound not delay closure or affect cosmesis? Any outcome data?

    • Brian Lin, MD, FACEP

      That’s a great question. I am currently working on finding the answer, working on a manuscript regarding long-term outcome on a series of patients in whom I have used this technique. Though the data is still incomplete at this point, so far, so good. The patients in whom I have spoken to at 3-6 months have had minimal to no scarring and very satisfactory cosmetic outcomes.

      • Throckmorton

        Any updates regarding healing and cosmesis? Just got a nastygram from plastics about dermabond in open wounds despite excellent hemostasis and patient satisfaction.

        • Brian Lin, MD, FACEP

          I’m so sorry to hear about your “nastygram.” Yes, I can understand where they would be coming from; the reviewers of my original article had similar concerns about this “off label” use of the product, despite many case reports pre-dating my technique discussing the use of cyanoacrylate glues within the open mediastinum, on blood vessels, on foot blisters, on mucous membranes, etc…the list goes on.
          Currently I have a modest case series of 6 patients with long term follow up of cosmesis after use of this technique that is in press in the journal “Advances in Skin & Wound Care.” The short version: no infections, and everyone happy with the cosmetic outcomes. I’ll be happy to share a link here when it is available. Until then, keep fighting the good fight!

  • Taku Taira

    Brian, great post: I would just add, the additional advantage of using the hemostat is that you are unlikely to ever forget to take it off. I have heard of many a case of orthopods forgetting to remove a penrose drain (which is flesh colored) or if you just use the ring portion of a glove. This is especially an important issue if the finger is blocked (blocking the pain from ischemia)… The other point is that a tip avulsion greater than 1 square centimeter cannot heal from the wound edges and may need a thenar or a cross finger flap…. There is also a package insert warning (not a contra-indication) about using it inside of wounds, because of concern for foreign body reaction, so it will be interesting to see the results of your study.

  • Mike

    How about gel foam or surgicel and some pressure?

    • A reasonable first step for the mild oozers. Brian’s trick is a great backup or maybe even a first-line approach to these bleeding avulsion injuries. It all depends on your preference, available supplies, and comfort level with these techniques. Can’t hurt to know multiple approaches!

      • Brian Lin, MD, FACEP

        agreed! actually I came up with this after I had failed one to many times with surgicel, direct pressure, and my promise to the patient that eventually the bleeding would stop.

        • Mike

          Agree with all. Seems like a great back up approach for one that persistently bleeds despite more conservative measures first.

  • Noonian Sisko

    Hello and thanks for yet another great tip!

    Quick question, and maybe it’s a stupid one, but…what about the epi and the fingertip’s circulation? I’m in Peds EM, and we often use LET (a mix of Lidocaine, Epinephrine, and Tetracaine) in gel-form to apply to wounds before cleaning/suturing to numb them without needles/injections, but it’s such a big no-no to apply that gel to fingertips/ear/tip of the nose etc that I’m wondering now if either we had it wrong all the time and topical epi is no big deal, or I’m missing an important distinction…
    Thanks for your help! :o)

    ~noonian

    • Brian Lin, MD, FACEP

      Hi Noonian, this is not a stupid question at all, as a matter of fact the expert peer reviewer of this blog post, Dr. Rob Bryant, made it a point that I address it. I will refer you to the expert peer review (above) for the more detailed response to this question with a good reference. Incidentally, I am also a fan of LET for pediatric wounds and I have applied it topically in all the anatomic areas you mentioned without any adverse sequelae. I believe the concern regarding epinephrine with regards to finger/ear/nose perfusion is more related to injection of the epi more proximally in to the blood supply of these areas (eg, the base of the finger during a digital block, with risk of digital artery vasoconstriction) rather than absorption topically. Thanks for reading and your question!

      • Noonian Sisko

        Oh, wonderful – thank you for your reply and for referring to the expert review and your answer there (hadn’t seen that before). I’ll happily to epi-dips and LET applications anywhere on the body now! :o)

      • John Haggarty MD

        Dr. David Newman has an entertaining podcast/lecture on pseudoaxioms… including a discussion about the lack of evidence behind the prohibition of lido+epi for digits.

  • Pik Mukherji

    Have used this approach w success in the past but the pain of adhesive glue on open wound has been limiting, so nerve block has been my go to. Has topical numbing failed you ever? I’ll have to try.
    Other issue is I’ve been told that I am using the adhesive in non approved, off label manner against manufacturer recs and w concerns like Dr. Dierckx in comments.

  • Annechien

    Another method is topical use of tranexamunic acid, either use the Iv solution or, messier but maybe even more effective, crushed tablets. There is some evidence out there even for topical use……

  • Josh Guttman

    Hi Brian,

    Thanks for the post and video. Had a dermal avulsion the other day, was all set up to use this technique. After soaking in 2% lido with epi for 15 minutes, the bleeding completely stopped. So I just applied some surgicel, watched for an hour and the bleeding never recurred. You mention in the post that it is a good start but “not enough”. At least with this n=1 it seemed to work. How often have you seen that the lido/epi combo worked without needing anything else? Do you find they end up coming back several hours later for re-bleeding? Or do you find that it’s sometimes enough but often not enough?

    Thanks,

    Josh

    • Brian Lin, MD, FACEP

      Thanks for the comment Josh. Glad to hear the bleeding stopped with just the lido/epi dip and surgicel. Answering your question is tough because these injuries vary considerably–for the smallest avulsions one usually doesn’t need more than just direct pressure and time; for larger avulsions some of the techniques described in my post come in to play. Keep in mind the spirit of my post is to give clinicians some additional back pocket tricks of the trade to care for a troublesome injury, but not necessarily a procedure that needs to be followed from A to Z each time. I think it is totally reasonable to take it one step at a time and see where your particular injury falls on the scale. I think the tissue adhesive glue technique is a nice “all else fails” technique and it can also be quite a timesaver in a busy department.

      Thanks again for reading and happy holidays!

  • Thank you so much for sharing this info
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